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The Bone & Joint Journal
Vol. 98-B, Issue 10 | Pages 1347 - 1354
1 Oct 2016
Palan J Smith MC Gregg P Mellon S Kulkarni A Tucker K Blom AW Murray DW Pandit H

Aims. Periprosthetic fracture (PF) after primary total hip arthroplasty (THA) is an uncommon but potentially devastating complication. This study aims to investigate the influence of cemented stem designs on the risk of needing a revision for a PF. Patients and Methods. We analysed data on 257 202 primary THAs with cemented stems and 390 linked first revisions for PF recorded in the National Joint Registry (NJR) of England, Wales and Northern Ireland to determine if a cemented femoral stem brand was associated with the risk of having revision for a PF after primary THA. All cemented femoral stem brands with more than 10 000 primary operations recorded in the NJR were identified. The four most commonly used cemented femoral stems were the Exeter V40 (n = 146 409), CPT (n = 24 300), C-Stem (n = 15 113) and Charnley (n = 20 182). We compared the revision risk ratios due to PF amongst the stems using a Poisson regression model adjusting for patient factors. Compared with the Exeter V40, the age, gender and ASA grade adjusted revision rate ratio was 3.89 for the cemented CPT stem (95% confidence interval (CI) 3.07 to 4.93), 0.89 for the C-Stem (95% CI 0.57 to 1.41) and 0.41 for the Charnley stem (95% CI 0.24 to 0.70). Conclusions. The limitations of the study include incomplete data capture, analysis of only PF requiring revision and that observation does not imply causality. Nevertheless, this study demonstrates that the choice of a cemented stem may influence the risk of revision for PF. Cite this article: Bone Joint J 2016;98-B:1347–54


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 5 | Pages 577 - 582
1 May 2009
Duncan WW Hubble MJW Howell JR Whitehouse SL Timperley AJ Gie GA

The removal of well-fixed bone cement from the femoral canal during revision of a total hip replacement (THR) can be difficult and risks the loss of excessive bone stock and perforation or fracture of the femoral shaft. Retaining the cement mantle is attractive, yet the technique of cement-in-cement revision is not widely practised. We have used this procedure at our hospital since 1989. The stems were removed to gain a better exposure for acetabular revision, to alter version or leg length, or for component incompatibility.

We studied 136 hips in 134 patients and followed them up for a mean of eight years (5 to 15). A further revision was required in 35 hips (25.7%), for acetabular loosening in 26 (19.1%), sepsis in four, instability in three, femoral fracture in one and stem fracture in one. No femoral stem needed to be re-revised for aseptic loosening.

A cement-in-cement revision of the femoral stem is a reliable technique in the medium term. It also reduces the risk of perforation or fracture of the femoral shaft.


The Journal of Bone & Joint Surgery British Volume
Vol. 80-B, Issue 4 | Pages 573 - 576
1 Jul 1998
Howie DW Middleton RG Costi K

We have compared prospectively the incidence of loosening of 20 femoral stems with a matt surface with that of 20 polished stems of an otherwise identical tapered, non-modular design of Exeter hip replacement. The stems were inserted using the same technique at operation and radiographs showed no difference in the adequacy of the cement mantle or of fixation. All the patients were reviewed regularly and none was lost to follow-up.

After a minimum follow-up of nine years, four matt but no polished stems had been revised for aseptic loosening. Polished stems subsided slightly within the cement mantle early, but did not loosen.


The Bone & Joint Journal
Vol. 96-B, Issue 3 | Pages 299 - 305
1 Mar 2014
Bell KR Clement ND Jenkins PJ Keating JF

We performed a case–control study to compare the rates of further surgery, revision and complications, operating time and survival in patients who were treated with either an uncemented hydroxyapatite-coated Corail bipolar femoral stem or a cemented Exeter stem for a displaced intracapsular fracture of the hip. The mean age of the patients in the uncemented group was 82.5 years (53 to 97) and in the cemented group was 82.7 years (51 to 99) We used propensity score matching, adjusting for age, gender and the presence or absence of dementia and comorbidities, to produce a matched cohort receiving an Exeter stem (n = 69) with which to compare the outcome of patients receiving a Corail stem (n = 69). The Corail had a significantly lower all-cause rate of further surgery (p = 0.016; odds ratio (OR) 0.18, 95% CI 0.04 to 0.84) and number of hips undergoing major further surgery (p = 0.029; OR 0.13, 95% CI 0.01 to 1.09). The mean operating time was significantly less for the Corail group than for the cemented Exeter group (59 min [12 to 136] vs 70 min [40 to 175], p = 0.001). The Corail group also had a lower risk of a peri-prosthetic fracture (p = 0.042; OR 0.19, 95% CI 0.01 to 1.42) . There was no difference in the mortality rate between the groups. There were significantly fewer complications in the uncemented group, suggesting that the use of this stem would result in a decreased rate of morbidity in these frail patients. Whether this relates to an improved functional outcome remains unknown.

Cite this article: Bone Joint J 2014;96-B:299–305.


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 7 | Pages 921 - 927
1 Jul 2005
Glyn-Jones S Gill HS Beard DJ McLardy-Smith P Murray DW

Polished, tapered stems are now widely used for cemented total hip replacement and many such designs have been introduced. However, a change in stem geometry may have a profound influence on stability. Stems with a wide, rectangular proximal section may be more stable than those which are narrower proximally. We examined the influence of proximal geometry on stability by comparing the two-year migration of the Exeter stem with a more recent design, the CPS-Plus, which has a wider shoulder and a more rectangular cross-section. The hypothesis was that these design features would increase rotational stability.

Both stems subsided approximately 1 mm relative to the femur during the first two years after implantation. The Exeter stem was found to rotate into valgus (mean 0.2°, sd 0.42°) and internally rotate (mean 1.28°, sd 0.99°). The CPS-Plus showed no significant valgus rotation (mean 0.2°, sd 0.42°) or internal rotation (mean −0.03°, sd 0.75°). A wider, more rectangular cross-section improves rotational stability and may have a better long-term outcome.


The Journal of Bone & Joint Surgery British Volume
Vol. 86-B, Issue 7 | Pages 974 - 978
1 Sep 2004
Thomas SR Shukla D Latham PD

Cemented titanium stems in hip arthroplasty are associated with proximal cement-stem debonding and early failure. This was well publicised with the 3M Capital hip. However, corrosion in this setting has been reported with only one stem design and is less widely accepted.

We present a series of 12 cemented titanium Furlong Straight Stems which required revision at a mean of 78 months for thigh pain. At revision the stems were severely corroded in a pattern which was typical of crevice corrosion. Symptoms were eliminated after revision to an all-stainless steel femoral prosthesis of the same design. We discuss the likely causes for the corrosion. The combination of a titanium stem and cement appears to facilitate crevice corrosion.


The Journal of Bone & Joint Surgery British Volume
Vol. 83-B, Issue 6 | Pages 838 - 842
1 Aug 2001
Chambers IR Fender D McCaskie AW Reeves BC Gregg PJ

The radiological features of the cement mantle around total hip replacements (THRs) have been used to assess aseptic loosening. In this case-control study we investigated the risk of failure of THR as predictable by a range of such features using data from patients recruited to the Trent Regional Arthroplasty Study (TRAS).

An independent radiological assessment was undertaken on Charnley THRs with aseptic loosening within five years of surgery and on a control group from the TRAS database. Chi-squared tests were used to test the probability of obtaining the observed data by chance, and odds ratios were calculated to estimate the strength of association for different features.

Several features were associated with a clinically important increase (> twofold) in the risk of loosening, which was statistically significant for four features (p < 0.01). Inadequate cementation (Barrack C and D grades) was the most significant feature, with an estimated odds ratio of 9.5 (95% confidence interval 3.2 to 28.4, p < 0.0001) for failure.


The Bone & Joint Journal
Vol. 103-B, Issue 7 Supple B | Pages 46 - 52
1 Jul 2021
McGoldrick NP Fischman D Nicol GM Kreviazuk C Grammatopoulos G Beaulé PE

Aims. The aim of this study was to radiologically evaluate the quality of cement mantle and alignment achieved with a polished tapered cemented femoral stem inserted through the anterior approach and compared with the posterior approach. Methods. A comparative retrospective study of 115 consecutive hybrid total hip arthroplasties or cemented hemiarthroplasties in 110 patients, performed through anterior (n = 58) or posterior approach (n = 57) using a collarless polished taper-slip femoral stem, was conducted. Cement mantle quality and thickness were assessed in both planes. Radiological outcomes were compared between groups. Results. No significant differences were identified between groups in Barrack grade on the anteroposterior (AP) (p = 0.640) or lateral views (p = 0.306), or for alignment on the AP (p = 0.603) or lateral views (p = 0.254). An adequate cement mantle (Barrack A or B) was achieved in 77.6% (anterior group, n = 45) and in 86% (posterior group, n = 49), respectively. Multivariate analysis revealed factors associated with unsatisfactory cement mantle (Barrack C or D) included higher BMI, left side, and Dorr Type C morphology. A mean cement mantle thickness of ≥ 2 mm was achieved in all Gruen zones for both approaches. The mean cement mantle was thicker in zone 7 (p < 0.001) and thinner in zone 9 for the anterior approach (p = 0.032). Incidence of cement mantle defects between groups was similar (6.9% (n = 4) vs 8.8% (n = 5), respectively; p = 0.489). Conclusion. An adequate cement mantle and good alignment can be achieved using a collarless polished tapered femoral component inserted through the anterior approach. Cite this article: Bone Joint J 2021;103-B(7 Supple B):46–52


The Bone & Joint Journal
Vol. 100-B, Issue 12 | Pages 1565 - 1571
1 Dec 2018
Kristensen TB Dybvik E Furnes O Engesæter LB Gjertsen J

Aims. The aim of this large registry-based study was to compare mid-term survival rates of cemented femoral stems of different designs used in hemiarthroplasty for a fracture of the femoral neck. Patients and Methods. From the Norwegian Hip Fracture Register (NHFR), 20 532 primary cemented bipolar hemiarthroplasties, which were undertaken in patients aged > 70 years with a femoral neck fracture between 2005 and 2016, were included. Polished tapered stems (n = 12 065) (Exeter and CPT), straight stems (n = 5545) (Charnley, Charnley Modular, and Spectron EF), and anatomical stems (n = 2922) (Lubinus SP2) were included. The survival of the implant with any reoperation as the endpoint was calculated using the Kaplan–Meier method and hazard ratios (HRs), and the different indications for reoperation were calculated using Cox regression analysis. Results. The one-year survival was 96.0% (95% confidence interval (CI) 95.6 to 96.4) for the Exeter stem, 97.0% (95% CI 96.4 to 97.6) for the Lubinus SP2 stem, 97.6% (95% CI 97.0 to 98.2) for the Charnley stem, 98.1% (95% CI 97.3 to 98.9) for the Spectron EF stem, and 96.4% (95% CI 95.6 to 97.2) for the Charnley Modular stem, respectively. The hazard ratio for reoperation after one year was lower for Lubinus SP2 (HR 0.77, 95% CI 0.60 to 0.97), Charnley (HR 0.64, 95% CI 0.48 to 0.86), and Spectron EF stems (HR 0.44, 95% CI 0.29 to 0.67) compared with the Exeter stem. Reoperation for periprosthetic fracture occurred almost exclusively after the use of polished tapered stems. Conclusion. We were able to confirm that implant survival after cemented hemiarthroplasty for a hip fracture is high. Differences in rates of reoperation seem to favour anatomical and straight stems compared with polished tapered stems, which had a higher risk of periprosthetic fracture


The Bone & Joint Journal
Vol. 98-B, Issue 12 | Pages 1611 - 1619
1 Dec 2016
Wilson MJ Hook S Whitehouse SL Timperley AJ Gie GA

Aims. Femoral impaction bone grafting was first developed in 1987 using morselised cancellous bone graft impacted into the femoral canal in combination with a cemented, tapered, polished stem. We describe the evolution of this technique and instrumentation since that time. . Patients and Methods. Between 1987 and 2005, 705 revision total hip arthroplasties (56 bilateral) were performed with femoral impaction grafting using a cemented femoral stem. All surviving patients were prospectively followed for a mean of 14.7 years (9.8 to 28.3) with no loss to follow-up. By the time of the final review, 404 patients had died. Results. There were 76 further revisions (10.8%) involving the stem; seven for aseptic loosening, 23 for periprosthetic fracture, 24 for infection, one for malposition, one for fracture of the stem and 19 cement-in-cement exchanges of the stem during acetabular revision. The 20-year survival rate for the entire series was 98.8% (95% confidence interval (CI) 97.8 to 99.8) with aseptic loosening as the endpoint, and 87.7% (95% CI 82.8 to 92.6) for revision for any reason. Survival improved with the evolution of the technique, although this was not statistically significant due to the overall low rate of further revision. Conclusion. This is the largest series of revision total hip arthroplasties with femoral impaction grafting, and the results support the continued use of this technique. Cite this article: Bone Joint J 2016;98-B:1611–19


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 3 | Pages 315 - 320
1 Mar 2006
Field RE Singh PJ Latif AMH Cronin MD Matthews DJ

We describe the results at five years of a prospective study of a new tri-tapered polished, cannulated, cemented femoral stem implanted in 51 patients (54 hips) with osteoarthritis. The mean age and body mass index of the patients was 74 years and 27.9, respectively. Using the anterolateral approach, half of the stems were implanted by a consultant orthopaedic surgeon and half by six different registrars. There were three withdrawals from the study because of psychiatric illness, a deep infection and a recurrent dislocation. Five deaths occurred prior to five-year follow-up and one patient withdrew from clinical review. In the remaining 51 hips the mean pre-operative Oxford hip score was 47 points which decreased to 19 points at five years (45 hips). Of the stems 49 (98%) were implanted within 1° of neutral in the femoral canal. The mean migration of the stem at five years was 1.9 mm and the survivorship for aseptic loosening was 100%. There was no significant difference in outcome between the consultant and registrar groups. At five years, the results were comparable with those of other polished, tapered, cemented stems. Long-term surveillance continues


Bone & Joint Open
Vol. 4, Issue 3 | Pages 198 - 204
16 Mar 2023
Ramsay N Close JCT Harris IA Harvey LA

Aims

Cementing in arthroplasty for hip fracture is associated with improved postoperative function, but may have an increased risk of early mortality compared to uncemented fixation. Quantifying this mortality risk is important in providing safe patient care. This study investigated the association between cement use in arthroplasty and mortality at 30 days and one year in patients aged 50 years and over with hip fracture.

Methods

This retrospective cohort study used linked data from the Australian Hip Fracture Registry and the National Death Index. Descriptive analysis and Kaplan-Meier survival curves tested the unadjusted association of mortality between cemented and uncemented procedures. Multilevel logistic regression, adjusted for covariates, tested the association between cement use and 30-day mortality following arthroplasty. Given the known institutional variation in preference for cemented fixation, an instrumental variable analysis was also performed to minimize the effect of unknown confounders. Adjusted Cox modelling analyzed the association between cement use and mortality at 30 days and one year following surgery.


The Bone & Joint Journal
Vol. 106-B, Issue 5 | Pages 435 - 441
1 May 2024
Angelomenos V Mohaddes M Kärrholm J Malchau H Shareghi B Itayem R

Aims

Refobacin Bone Cement R and Palacos R + G bone cement were introduced to replace the original cement Refobacin Palacos R in 2005. Both cements were assumed to behave in a biomechanically similar fashion to the original cement. The primary aim of this study was to compare the migration of a polished triple-tapered femoral stem fixed with either Refobacin Bone Cement R or Palacos R + G bone cement. Repeated radiostereometric analysis was used to measure migration of the femoral head centre. The secondary aims were evaluation of cement mantle, stem positioning, and patient-reported outcome measures.

Methods

Overall, 75 patients were included in the study and 71 were available at two years postoperatively. Prior to surgery, they were randomized to one of the three combinations studied: Palacos cement with use of the Optivac mixing system, Refobacin with use of the Optivac system, and Refobacin with use of the Optipac system. Cemented MS30 stems and cemented Exceed acetabular components were used in all hips. Postoperative radiographs were used to assess the quality of the cement mantle according to Barrack et al, and the position and migration of the femoral stem. Harris Hip Score, Oxford Hip Score, Forgotten Joint Score, and University of California, Los Angeles Activity Scale were collected.


The Bone & Joint Journal
Vol. 106-B, Issue 6 | Pages 540 - 547
1 Jun 2024
Nandra RS Elnahal WA Mayne A Brash L McBryde CW Treacy RBC

Aims

The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active patients using a historically proven large-diameter metal-on-metal (MoM) bearing. A single designer surgeon’s consecutive series of 130 patients (144 hips) was previously reported at five and ten years, reporting three and ten failures, respectively. The aim of this study was to extend the follow-up of this original cohort at 25 years.

Methods

The study extends the reporting on the first consecutive 144 resurfacing procedures in 130 patients for all indications. All operations were undertaken between August 1997 and May 1998. The mean age at operation was 52.1 years (SD 9.93; 17 to 76), and included 37 female patients (28.5%). Failure was defined as revision of either component for any reason. Kaplan-Meier survival analysis was performed. Routine follow-up with serum metal ion levels, radiographs, and Oxford Hip Scores (OHSs) was undertaken.


The Journal of Bone & Joint Surgery British Volume
Vol. 83-B, Issue 5 | Pages 680 - 685
1 Jul 2001
Bowditch M Villar R

Early failures have seen titanium fall from favour as a material for cemented femoral stems. Between 1989 and 1994, we performed a prospective review of a consecutive series of 122 cemented total hip replacements using the Ultima straight textured titanium stem, and report the five- to ten-year clinical and radiological outcomes. There were no revisions for loosening of the femoral stem. Revision surgery was undertaken for other reasons such as dislocation, infection and loosening of the cup in 7.3%. Of those patients without revision all but two were satisfied with their hip, with 74% graded good or excellent using a modified Harris hip score. Radiological assessment revealed probable loosening in two. Although slight vertical subsidence was found in one-third of patients it had not progressed to loosening. It is not clear whether this represents debonding. Non-progressive radiolucent lines (1 to 2 mm) were present in zone 1 at the cement-prosthesis interface in 14.7%. Calcar resorption and hypertrophy around the distal stem were not often seen. With 97% survival at a mean of 7.5 years, the medium-term results of this specific cemented titanium stem are reassuring so far, but we are concerned about debonding and future failure


The Bone & Joint Journal
Vol. 104-B, Issue 2 | Pages 212 - 220
1 Feb 2022
Fishley WG Selvaratnam V Whitehouse SL Kassam AM Petheram TG

Aims

Femoral cement-in-cement revision is a well described technique to reduce morbidity and complications in hip revision surgery. Traditional techniques for septic revision of hip arthroplasty necessitate removal of all bone cement from the femur. In our two centres, we have been using a cement-in-cement technique, leaving the distal femoral bone cement in selected patients for septic hip revision surgery, both for single and the first of two-stage revision procedures. A prerequisite for adoption of this technique is that the surgeon considers the cement mantle to be intimately fixed to bone without an intervening membrane between cement and host bone. We aim to report our experience for this technique.

Methods

We have analyzed patients undergoing this cement-in-cement technique for femoral revision in infection, and present a consecutive series of 89 patients. Follow-up was undertaken at a mean of 56.5 months (24.0 to 134.7) for the surviving cases.


Bone & Joint Open
Vol. 2, Issue 7 | Pages 466 - 475
8 Jul 2021
Jain S Lamb J Townsend O Scott CEH Kendrick B Middleton R Jones SA Board T West R Pandit H

Aims

This study evaluates risk factors influencing fracture characteristics for postoperative periprosthetic femoral fractures (PFFs) around cemented stems in total hip arthroplasty.

Methods

Data were collected for PFF patients admitted to eight UK centres between 25 May 2006 and 1 March 2020. Radiographs were assessed for Unified Classification System (UCS) grade and AO/OTA type. Statistical comparisons investigated relationships by age, gender, and stem fixation philosophy (polished taper-slip (PTS) vs composite beam (CB)). The effect of multiple variables was estimated using multinomial logistic regression to estimate odds ratios (ORs) with 95% confidence intervals (CIs). Surgical treatment (revision vs fixation) was compared by UCS grade and AO/OTA type.


Bone & Joint Open
Vol. 2, Issue 6 | Pages 443 - 456
28 Jun 2021
Thompson JW Corbett J Bye D Jones A Tissingh EK Nolan J

Aims

The Exeter V40 cemented polished tapered stem system has demonstrated excellent long-term outcomes. This paper presents a systematic review of the existing literature and reports on a large case series comparing implant fractures between the Exeter V40 series; 125 mm and conventional length stem systems.

Methods

A systematic literature search was performed adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. In parallel, we performed a retrospective single centre study of Exeter V40 femoral stem prosthetic fractures between April 2003 and June 2020.


The Bone & Joint Journal
Vol. 103-B, Issue 8 | Pages 1339 - 1344
1 Aug 2021
Jain S Mohrir G Townsend O Lamb JN Palan J Aderinto J Pandit H

Aims

This aim of this study was to assess the reliability and validity of the Unified Classification System (UCS) for postoperative periprosthetic femoral fractures (PFFs) around cemented polished taper-slip (PTS) stems.

Methods

Radiographs of 71 patients with a PFF admitted consecutively at two centres between 25 February 2012 and 19 May 2020 were collated by an independent investigator. Six observers (three hip consultants and three trainees) were familiarized with the UCS. Each PFF was classified on two separate occasions, with a mean time between assessments of 22.7 days (16 to 29). Interobserver reliability for more than two observers was assessed using percentage agreement and Fleiss’ kappa statistic. Intraobserver reliability between two observers was calculated with Cohen kappa statistic. Validity was tested on surgically managed UCS type B PFFs where stem stability was documented in operation notes (n = 50). Validity was assessed using percentage agreement and Cohen kappa statistic between radiological assessment and intraoperative findings. Kappa statistics were interpreted using Landis and Koch criteria. All six observers were blinded to operation notes and postoperative radiographs.


The Bone & Joint Journal
Vol. 103-B, Issue 7 Supple B | Pages 33 - 37
1 Jul 2021
Ennin KA Elsharkawy KA Dasgupta S Emerson RH

Aims

To achieve the functional benefits of the direct anterior (DA) approach and the fixation benefits of cemented replacement, this study combined the two techniques posing the following questions: does the limited access of the DA approach adversely affect the cement technique?; and does such a cementing technique reduce the incidence of cementless complications?

Methods

A consecutive series of 341 patients (360 hips) receiving the DA approach between 2016 and 2018 were reviewed. There were 203 cementless stems and 157 cemented stems. Mean age was 75 years (70 to 86) in the cementless group and 76 years (52 to 94) in the cemented group, with 239 (70%) females in the whole series. Femoral complications were compared between the two groups. Mean follow-up was 1.5 years (0.1 to 4.4) for patients in the cementless group and 1.3 years (0.0 to 3.9) for patients in the cemented group.